From the Guidelines
I strongly recommend that this 71-year-old male with a PSA of 8.28 ng/mL and a family history of prostate cancer undergo prompt urological evaluation, including a referral to a urologist for consideration of prostate biopsy, as his elevated PSA level and family history increase his risk of prostate cancer 1.
Key Considerations
- The patient's PSA level is significantly above the normal range, which increases the likelihood of prostate cancer, especially given his family history of the disease 1.
- The American Cancer Society guideline emphasizes the importance of informing patients about the risks and benefits of intervention, particularly for men at high risk or advanced age 1.
- A prostate biopsy is the definitive test for diagnosing prostate cancer, and the urologist will likely perform a digital rectal examination and may order additional tests to assess cancer risk before deciding on biopsy 1.
Diagnostic Evaluation
- The urologist may order additional tests such as a free PSA test, prostate MRI, or the 4Kscore test to better assess cancer risk before deciding on biopsy.
- If a biopsy is performed and cancer is detected, treatment options would depend on the Gleason score, cancer stage, and the patient's overall health status, potentially including active surveillance, radiation therapy, or surgery.
Importance of Evaluation
- Age alone should not preclude appropriate diagnostic evaluation, as many 71-year-olds have a life expectancy that would justify treatment if significant cancer is found 1.
- The elevated PSA could also be due to benign prostatic hyperplasia or prostatitis, but given the family history and PSA level, further evaluation is necessary to rule out cancer 1.
From the Research
Patient Profile
- Age: 71 years
- PSA level: 8.28
- Family history: Father had prostate cancer
- Symptoms: None
Diagnostic Approach
- Multiparametric magnetic resonance imaging (mpMRI) is a reliable tool for detecting clinically significant prostate cancer (csPCa) 2, 3, 4
- mpMRI has excellent sensitivity in detecting csPCa, but its clinical utility in patients with negative results is less clear 2
- A study found that mpMRI had a sensitivity of 96% and a specificity of 36% in detecting significant prostate cancer 5
Risk Factors
- Increasing age is an independent predictor of lower csPCa diagnosis probability 2
- Increasing prostate-specific antigen (PSA) and PSA density are independent predictors of higher csPCa diagnosis probability 2
- Family history of prostate cancer is a risk factor for developing the disease
Next Steps
- Consider performing an mpMRI to evaluate the prostate and detect any potential csPCa 3, 4, 6
- If mpMRI results are negative, systematic biopsy may still be recommended, especially in patients with high clinical suspicion of prostate cancer 2
- The use of PI-RADS scoring system can help in accurate interpretation of mpMRI results 3, 5